The funding level for this activity in FY 2008 has increased since FY 2007. Narrative changes include

updates on progress made and expansion of activities.

The Churches Health Association of Zambia (CHAZ) is an interdenominational non-governmental umbrella

organization of church health facilities formed in 1970. The organization has 125 affiliates that consist of

hospitals, rural health centers, and community based organizations. All together these member units are

responsible for 50% of formal health care service in the rural areas of Zambia and about 30% of health care

in the country as a whole. CHAZ, in collaboration with the Global Fund, started supporting the ART as well

as the prevention of mother to child transmission of HIV/AIDS (PMTCT) program during 2006 and currently

has 20 sites implementing PMTCT.

In FY 2007, CHAZ supported its mission institutions to meet the needs of the communities they served. The

knowledge and skills of the health care providers was strengthened in order to prevent the transmission of

mother to child transmission of HIV, and to ensure sound follow-up of HIV-exposed infants. By

strengthening institutional capacity, and facilitating active community involvement, CHAZ continued to

advocate for community participation and male involvement in PMTCT. Through this intervention, CHAZ

addressed issues of gender inequality by providing yet another avenue for HIV positive women to access

ART, thus improving their chances for survival and their continued ability to care for their families.

In order to ensure the success of this activity, in FY 2007, all cadres of healthcare providers who care for

pregnant women and infants were trained to provide high-quality counseling and care to HIV positive

pregnant women, including provision of ARV drugs, and support for infant feeding options. CHAZ continued

to strengthen linkages between local partner health facilities and the surrounding communities they served.

Community members took part in outreach activities that promoted PMTCT awareness and developed

supportive networks for HIV positive women in the post-partum period, especially as it related to maintaining

their chosen infant feeding option, and for encouraging infant follow-up for definitive diagnosis.

FY 2008 activities will result in: (1) increased access to quality PMTCT services; (2) quality PMTCT services

integrated into routine maternal and child health services; (3) increased use of complete course of

antiretroviral (ARV) prophylaxis by HIV-positive women; (4) improved referral to ARV treatment programs;

(5) linkage between child health, ART, PMTCT services and increased community participation; (6)

increased knowledge of health providers/staff in neonate and child early clinical identification of exposed

babies; and (7) early infant diagnosis using DNA-PCR test on dried blood spot.

During FY 2008, CHAZ will continue to strengthen provision of quality PMTCT services in the 25 mission

institutions with a focus on coverage and sustainability. This will be accomplished by building the capacity of

health care providers in PMTCT and follow-up of HIV exposed infants and HIV positive mothers after

delivery. For the infants that test negative after the definitive diagnosis has been made, support will be

provided for strengthening of infant feeding options through support of infant feeds. This strategy will also

ensure timely treatment provision to infants testing HIV positive. Mothers will also be monitored closely after

delivery so that they begin treatment early.

To ensure continued access to routine counseling and testing (CT) for pregnant women, all pregnant

women will receive routine HIV testing with improved antenatal clinic (ANC) services at 25 sites. Support

will also be provided for establishing referral linkages between the ANC, delivery ward, and ART clinics

(general and Paediatric), so that each HIV positive pregnant woman can receive CD4 testing and to

determine and provide therapy options. Counseling on infant feeding, with well articulated plans for infant

follow-up, will be made during the antenatal period, and this will be followed-up after the dried blood spot

test. Referral linkages will also be strengthened between the ANC, delivery wards, and the ARV clinics in all

facilities, to ensure appropriate care for the mother and newborn in accordance with the national guidelines.

Awareness training of local traditional birth attendants (TBAs) will also be done to ensure adequate peri-

partum /post partum interventions for the mothers and newborns where deliveries are done outside the

health facilities.

Activities in FY 2008 will include: (1) training antenatal and delivery ward staff on PMTCT interventions; (2)

training TBAs; (3) establishing/strengthening referral linkages within the health facility and with selected

trained TBAs; (4) strengthening of laboratory capacity to accommodate the increased numbers of HB, CD4

and hematology tests required for pregnant women identified as HIV-positive; (5) Infant feeding training for

all cadres of health workers and key women in the communities; (6) training of staff in the ‘well-baby clinic'

on how to follow-up and make a definitive HIV diagnosis on HIV-exposed infants; (7) strengthening

laboratory capacity to send samples to national infant diagnosis of HIV centers; and (8) training of doctors

and clinical officers in early diagnosis and timely intervention for the HIV-exposed infant. This component

will establish the necessary linkages among the health facilities and communities to ensure adequate infant

follow-up, definitive HIV diagnosis, and stronger laboratory capacity.

The final component of FY 2008 activities will address: (1) community mobilization, including a targeted

evaluation of male involvement and participation in the PMTCT program through community outreach

activities; and (2) awareness training targeted at men. This activity will support awareness campaigns, train

community men, and establish or strengthen linkages between the health facilities and the community.

Targets set for this activity cover a period ending September 30, 2009.

The funding level for this activity in FY 2008 will remain the same as in FY 2007. Only minor narrative

updates have been made to highlight progress and achievements.

Acute human resource shortages in Zambia, particularly in rural areas, necessitate the need for innovative

ways to deliver quality patient care and management. The Churches Health Association of Zambia (CHAZ)

is an interdenominational, non-governmental umbrella organization of church health facilities which was

formed in 1970. The organization has 129 affiliates that consist of hospitals, rural health centers and

community based organizations. All together these member units are responsible for 50% of formal health

care service in the rural areas of Zambia and about 30% of health care in the country as a whole. CHAZ

collaborates well with the Ministry of Health and other stakeholders including CDC in TB control. CHAZ is

one of the four Principal Recipients for The Global Fund to disburse resources in Zambia. Three

agreements in HIV/AIDS, TB and Malaria were signed. In July 2005, CHAZ signed as additional agreement

under Round 4 of The Global Fund to scale ART services in Church Health Institutions.

The comparative advantage CHAZ has is its area of operation which mainly is rural, thus heavily involved in

the development and utilization of community-level volunteers to assist with TB treatment adherence and

support by regular community volunteer visits to the patients home to ‘directly-observe therapy' and to

provide a basic check-up. This is an innovative and cost-effective way to address severe health care

human capacity shortages by multiplying skills and knowledge through the population and further

empowering community members to appropriately care for such patients. Evidence has shown that such

community-based treatment supporters have improved TB treatment adherence and outcomes.

The goal of CHAZ TB control program is to improve the quality of TB care in order to reduce the number of

TB related deaths and increase the cure rate through the Stop TB Strategy. With FY07 funds from CDC,

CHAZ initiated the TB/HIV collaborative activities at its selected church health facilities, 34 mission/church

health institutions (CHIs) in four CDC priority Provinces (Southern, Western, Eastern, and Lusaka). In this

regard, 34 frontline health workers were trained in diagnostic counseling and testing (DCT). Training was

also extended to 115 TB community treatment supporters who were trained in the DOTs and TB/HIV

implementation. Treatment supporters were also provided with bicycles to enhance community DOT and

patient follow up at community level.

Suffice to say that the 34 health workers trained in DCT fall short of the 200 target that CHAZ set for itself in

FY07. This underachievement is due to the fact that at the time our training activities were about to

commence, the National TB and Control Program in the Ministry of Health embarked an exercise to review

the training manual and the data reporting tools(registers and report forms). CHAZ made a decision to delay

training in order to make use of the new training manual, report form and patient register. This activity also

affected the training of community treatment supporters as only 115 were trained against the 400 that was

targeted for in FY07.

To further strengthen linkages between TB and HIV/AIDS activities and strengthen the Stop TB Strategy in

Zambia, CHAZ will in FY08 continue with and strengthen activities begun in FY07 in order to scale up to 44

sites. This geographic and programmatic expansion will be accomplished by mobilizing communities,

strengthening the IEC component to include local languages; and continuing to build capacities of both

CHIs and local communities in the STOP TB Strategy. Specifically CHAZ will continue with following

strategies/activities:

•Facilitate and strengthen therapeutic TB/HIV meetings at community level for co- infected patients/clients;

•Strengthen integration of TB/HIV at all levels through quarterly meetings;

•Increase number of frontline health care workers trained in DCT from 34 to 250. The training will address

issues related to TB and HIV treatment. After training, health facility workers will provide support to

community treatment supporters through technical supervision as an on going activity to ensure

maintenance of proper standards in TB/HIV collaborative activities at community level. The trained health

care providers will receive follow up technical supervision from the district, provincial, CHAZ and National

program to sharpen their skills.

•Increase number of community treatment supporters trained in basic TB/HIV link and counseling from 115

to 600. It is expected that these will supervise treatment in 1,309 co-infected patients that are unable or

unwilling to make regular visits to the health facilities;

•Design and produce IEC materials using both electronic and print media on TB/HIV. Use of local drama

performances will also be encouraged to create awareness in TB control;

•Strengthen the referral to ensure that health care workers are competent in the use of data collection and

reporting systems at CHAZ health facilities and community levels

•Strengthen the monitoring and evaluation at CHAZ health facilities by improving capacity of the TB desk at

CHAZ secretariat with the employment of one TB officer; To enhance the capacity for monitoring and

evaluation of TB/HIV program the technical supervision visits will include a component of training in the use

of information for management decisions at health facility level.

•Improve infrastructure (minor renovations and improve ventilation ) for TB/HIV services at CHAZ (mission)

health facility level: This activity will facilitate reduction of transmission of infection from un diagnosed and

newly diagnosed smear positive TB patients to HIV infected clients and health care providers. The

renovations would be specific to the sites and may include improving the ventilation in waiting areas.

In FY08, activities will be implemented in the same 4 Provinces (Southern, Western, Eastern, and Lusaka).

Support of community volunteers/treatment supporters will be enhanced to provide quality home-based care

that includes TB/HIV integration elements such as skills for linking home-based TB patients to HIV

counseling and testing and HIV care services including ART services. Despite the rural set up of most of the

CHAZ health institutions, it is expected that about 75% of the TB patients referred to ART services will

receive care and support. The TB patients found eligible for ART will be commenced on treatment

according to the National guidelines. A system to track the referrals and ART treatment will be developed.

Standardized training will also be given to community-volunteers so that they may continue to provide home

-based care for patients found to be TB/HIV co-infected e.g. TB and ART treatment adherence, monitoring

for treatment of side effects. This type of service delivery is especially appropriate for TB/HIV patients as

are generally sicker and less able to reach health facility-based care.

Community treatment supporters will be provided with bicycles and home-based care kits each. In this way,

we hope to improve their morale, strengthen volunteer retention and improve service delivery. Utilization of

Activity Narrative: already existing structures and systems such as home care programmes and involvement of community

volunteers can promote community participation and programme ownership, thereby leading to program

sustainability. CHAZ can boast of decades of community mobilization and partnerships experience through

mission hospitals and health centres in rural Zambia. We will use this experience to mobilize local

communities towards the Stop TB campaign and to enhance TB/HIV collaboration. Weaknesses have been

noted in the integration of TB and HIV/AIDS programmes at both the health facility level and community. It

is hoped that CDC funding will also facilitate a strong linkage between the Global Fund component of the

TB and HIV/AIDS programmes. CHAZ is not implementing the use of Isoniazid preventive therapy to HIV

infected clients since it does not form part of the national guidelines for TB/HIV activities. How ever, should

the Ministry of Health adopt this intervention, CHAZ will implement IPT. The National guidelines

recommends the use of IPT in under five (5) children whose mothers are sputum smear positive for TB and

CHAZ will implement this activity.

CHAZ is confident that planned activities and targets set for FY 08 will be accomplished given the fact that

we now not only have trainers in each of the nine provinces in Zambia; the training manual and data

reporting tools including patient registers and reporting forms are operational. FY08 activities will result in:

(i) High quality of health care delivery of CHIs providing counseling and testing according to the national

guidelines; (ii) increased in the number of HIV infected patients attending care / treatment services that are

receiving treatment for TB; (iii) increased number of health workers (100) and community volunteers (150)

trained to provide treatment for TB to HIV infected individuals and community treatment supporters; and (iv)

increased number of registered TB patients ( 2000) who receive counseling and testing for HIV and

received their test results at USG supported TB service outlet.

Targets set for this activity cover a period ending September 30, 2009.

The funding level for this public private partnership (PPP) activity in FY 2008 has increased since FY 2006

as this activity did not receive FY 2007 funding. However, it did receive funding in FY 2006 and the

activities desribed below are a continuation of the FY 2006 funded activites. Narrative changes include

updates on progress made and expansion of activities.

The LinkNet activity will continue to bring the fight against HIV-AIDS to some of the harder to reach districts

in Zambia. This activity improves the quality of HIV Care, Prevention, and Treatment by establishing locally

sustained deployment of the essential health communications, clinical medical records, and management

information systems needed for sustaining quality care in poorly connected remote locations.

These improvements are achieved though a partnering with private partner PrivaServe Foundation for the

deployment of reliable quality, locally run ICT (Information and Communications Technology) services in an

increasing number of remote hospitals ‘nodes' and their communities in Zambia thereby leveraging the

scaling-up, support and sustainability of the Zambia Ministry of Health (MOH) SmartCare ‘smart card'

Electronic Health Record (EHR) system of care in ‘feeder' clinics in the vicinity of these hospitals -

improving the numbers of people receiving care and preventive services, and the quality and sustainability

of that care.

As a very late funded 2006 Public-Private Partnership (PPP) the "LinkNet" continuation activity will extend

the proof of concept demonstrated by PrivaServe Foundation at Macha in 2006 and 2007, into an

increasing number of other similar remote hospital and clinic locations in Zambia by continuing to ‘clone' the

Macha and now early Mukinge successes. These successes are measured in part by the high degree of

local buy-in, community skills acquisition levels, stewardship and other elements of long term sustainability,

in addition to the direct and indirect clinical services benefits.

This activity continuation positively affects the quality of treatment to thousands of HIV/AIDS patients, and

extends the means to disseminate information directly to (and from) providers, improving management of

HIV Care, and Prevention - and as a side effect, improving local retention of otherwise more isolated

clinicians. There already exists a strong working relationship between LinkNet and CHAZ upon which this

collaboration builds.

The individual level EHR information resulting from routine provision of care, will, through SmartCare in

aggregate form, automatically feeds the national Health Management Information System from these same

sites, improving the quality, timeliness, and richness of this existing Zambian information stream, and

removing the separate burden of collecting this service management information that is key for budgeting,

logistics and supply.

The SmartCare system of care provides structure to clinical protocols, such as the provision of antiretroviral

therapy or prevention to mother to child transmission of HIV, according to best practices developed in

Lusaka, Zambia over the past several years, where over 85,000 HIV positive persons are now cared for

using this approach. In April, 2006, the MOH identified this President's Emergency Plan for AIDS Relief

(PEPFAR) facilitated software collaboration product as the national standard for provision ART care and

required its use. The number of other collaborators in this ongoing EHR development and implementation

effort in 2007 has increased to nearly 15 organizations (including LinkNet) following national training in June

2007. The MOH has requested for support to scale up the system nationally, implementing 900 sites within

the next two years.

The LinkNet activity leverages both this SmartCare success and the success of the LinkNet proof of

concept for community sustainable ICT rural hospital projects in Macha and now, in other similar project

sites in rural Zambia, to help in the national deployment and linking of this new national health information

system.

Targets set for this activity cover a period ending September 30, 2009.